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Quoting briefly: "A new Oregon State University study has found that postmenopausal women who participate in a long-term fitness regimen that includes jumping and "resistance" exercises using weighted vests can prevent significant bone loss in the hip. "In some cases, the researchers say, the bone density of elderly women who participated in the OSU study actually increased. Results of the five-year study have been accepted for a forthcoming issue of the Journal of Gerontology: Medical Sciences." The release goes on to say that the exercise program also reduced the risk of falls by improving women's strength and balance, and quotes princial investigator Christine Snow as saying, "Exercise was as good or better than either estrogen or Fosamax for preventing bone loss." The complete news release can be found at http://osu.orst.edu/dept/ncs/newsarch/2000/May00/boneloss.htm The release didn't mention the study size, so I just called Christine Snow and asked her. It was very small -- nine exercisers and nine controls. But she (and evidently the journal) was impressed enough with the consistency of the results to publish. (BTW, although the release mentions a specific jumping regimen, Snow said jumping rope would work equally well for those whose balance isn't already impaired, as long as you put in the requisite time. Then I asked -- on behalf of my office-mate -- "How about tap dancing?" She paused, laugghed, and said, "I don't see why not.") The abstract for the full five-year study isn't on line yet, but you can find one based on their earlier, one-year study of a larger group of pre-menopausal women at http://osu.orst.edu/hhp/resch/exss/abstracts/progressive_jump.html (and a whole bunch more of the lab's abstracts are at http://osu.orst.edu/hhp/resch/exss/bone.html) --Pat Kight
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| osteoporosis
prevention in an elderly woman with previous breast cancer
[email protected] (Fossachie) wrote My mother had breast cancer some 12 years ago, aged 71, treated by radical left-sided mastectomy. She was advised to take tamoxifen 'for life'. This is no longer current advice. However, last year, still taking it on doctor's orders, she found she was getting increasingly intense flushes; she knew this was a recognised side effect and at first tolerated them. But they became so intense as to be disabling and she refused to take it any more, saying she would prefer to die of cancer. She is well aware that kind people stopping in the street to see if they could help meant well but made things worse! It seems that her original cancer is now very unlikely to recur. Tamoxifen may protect against a new cancer. And, as important, at 83, it would help protect her against osteoporosis. She has not taken it for almost a year. The flushes are much reduced but still there. Is there a case for taking a reduced dose of tamoxifen? I know
some people think it is dreadful stuff and you should use 'natural'
remedies. My mother is a traditionalist and wants nothing to do with herbs,
oils, creams and nostrums. She wants to take her own decision, based on
the best information available, on a scientific basis. Her main concern
is osteoporosis protection. I am writing for her as she does not
have access to the NET I would be most grateful for information
about others experience, preferably backed by statistical rather
than anecdotal or individual evidence.
As a rheumatologist, I am loathe to comment on protection from breast cancer and I will not. However, I feel comfortable talking about osteoporosis. You state that your mother's primary concern is osteoporosis prevention. I take this to indicate that she does not at this time have evidence of osteoporosis and hence is not looking for treatment of established osteoporosis. There is a difference. You might consider in her history whether there is a family history of osteoporosis, whether she has lost height and how much since, say age 30, whether she has a marked dowager's hump or curvature of her back and whether she has broken any bones. You also don't tell us anything of her body build - is she petite or large, slender or obese. Is she fair haired, blue eyed and European in background? Did she or does she smoke? What's her alcohol consumption like now and previously. Is or was she on steroids, heparin, anticonvulsants? Does she have a history of depression? Does she have known kidney, liver disease or other chronic illness? Is she a heavy user of caffeinated beverages? What has her diet been like? These would all offer some clues as to the likelihood of osteoporosis. In addition, with a history of breast cancer, she has clearly had xray studies such as a chest x-ray. Now, it takes about 50% bone loss to see it on an x-ray but a positive x-ray for osteopenia would suggest she has osteoporosis at present. Now what can she do at 83 to prevent osteoporosis or to treat it? Simple things first 1. Calcium - 1500 mg daily - either in the form of dairy products, suppplemented soy beverages, lots of broccoli (10 cups), supplements or whatever. Diet is probably better than supplements. 2. At 83, she will absorb calcium less efficiently than at a younger age and she will produce her own active vitamin D less well, so she clearly needs supplemental vitamin D. In the absence of liver, intestinal or kidney disease, D3 is fine. If the above are present, I would measure the 1,25 hydroxy D level in blood. She will need 400 IU D3/day which is contained either in a calcium and D prep such as Citracel or Caltrate or in a multivitamin for the senior set. 3. Weight bearing exercise. Astronauts who are weight less lose bone. Your Mom needs regular weight bearing exercise - walking is fine; other possibilities depending on interest are dancing (ballroom, square or folk), golf, bowling, etc. She could also try using a treadmill and weight training in a supervised gym setting. If she is going to start this kind of program at the age of 83, she should be checked out by her internist and/or cardiologist. Patients even into their 90's can increase muscle mass through weight training. 4. Trace minerals - we are less certain about how much magnesium, boron, etc. and other trace minerals you need but she could certainly start with a multivitamin supplement. 5. What else - she could consider Fosamax - the dose for prevention is 5 mg daily; the dose for treatment of established osteoporosis is 10 mg. Frankly, because of its potential for esophageal problems, I'd personally like to know how osteoporotic she is before prescribing this. She could consider calcitonin nasal spray if she wants something safe, effective for treating osteoporosis and less potentially problematic. It is, however, expensive. I certainly wouldn't give her estrogen. There is no data available yet on raloxiphene and breast cancer but since it is associated with hot flashes, I strongly doubt your Mom would be interested in it once it becomes available next month. What else can she do to avoid fracture - which would be the goal? Other factors contribute to fracture in the elderly besides osteoporosis itself. They include declining vision, dangerous household environment with slippery tubs without guard rails, throw rugs, stuff underfoot. You might take a look at her household and figure out how to make it safer. Problems with balance contribute to who falls - so again, an exercise program to improve muscle strength and coordination pays dividends in decreased falls. Patients can even been taught how to fall. Finally my favorite - padding. You are all familiar with oone group of people in the society who are routinely padded to prevent hip fracture because we know they are at high risk. Yes, I'm talking about....... FOOTBALL - why do you think those guys wear those hip pads - it's to prevent hip fracture. I have been trying to figure out a way to make hip pads become de rigeur for elderly women - if we could make this fashionable or figurre out a way to make silk underpants with hip pads, we would impact the hip fracture statistics favorably. Hope this is useful. Regards, Dr Susan
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| research
on dental osteoporosis - cause and treatment
Just returned from a national Periodontology convention where dental researcher Robert Genco reported on his findings regarding osteo, and hormones on the impact on tooth loss. His conclusion was that depression was a major factor in bone loss and found there was a positive correlation between bone density loss and financial stresses. "Stress" increases the cortisol on the blood and "cortisone" type drugs have also been associated with bone density loss. Two other recent articles from NEJM and one other journal of good repute have also made this depression connection. And the "depression/stress" connection according to Genco comes more from inadequate coping skills and responses, not necessarily the "stressors" themselves. Back to that old mind/body disease precursor of an extended period of helplessness and hopelessness In a nutshell, Genco's other major finding was that smoking is the worst thing you can do to the bones holding your teeth in, regardless of hormone status. I had major problems with Genco's fundamental perception of the post-meno woman and made these clear in front of 900 other convention participants, but that will be for another post. Primarily he sees no biological difference between the surgical castrate and the post meno woman. To him they are hormonally interchangeable and he sees no reason to distinguish among them for research purposes.
He also believed the dentist should now aggressively encourage post meno
women to seek drugs for bone enhancement because his studies show you can
save one (!) tooth more if you are on life-long ERT. When asked if
the dentist should make the same recommendation for men suspected of being
osteoporotic, he boldly stated to all the convention participants that
there was inadequate testing to make these pro-drug recommendations for
men.
I could hardly sit still towards the end of his talk. I finally took the floor and asked" Since 60% of the women you have studied have been surgically castrated, are you not in fact studying the effects of surgical castration and not truly just the postmenopausal woman?" He blanched, gulped and said, do you mean hysterectomy and I said, no, I said "surgical castration" and this is when he responded that there was no difference between the two (surgical castration and normal post -meno)....but damn ...if he did not break out under the house lights on stage in a full on hot flash, beads of perspiration just glistening all over his head. I followed up my concerns in a 3 page letter to him yesterday. And after his talk I was approached by a female dental researcher who agreed with everything I was questioning and said until more women get into the basic research sciences, this sort of anomaly will continue. Junk in, junk out. I will share any response, should I receive any, from Dr. Genco. During the break when I approached him personally, he immediately claimed I had heard him all wrong and he was also being questioned on this same issue by a female reporter. After the break, when 90% of the audience was gone, he stated he did not mean to imply that estrogen was the only means of dealing with osteo. However, in a later talk, he continued to affirmatively, along with every other presenter at the convention, assert that there was no biologic difference between the surgically castrated and the normal post menopausal woman. I beg to differ with this conclusion and equally assert this is an inherent research flaw, until shown to be the case only by selecting out the two groups in all future research. Science marches on. So if your dentist now joins in this evangelical estrogen pushing, please consider the source of the "facts." And that not one single reference was made to assess the risk/benefit ratio of castration and a life-time estrogen use in order to save one theoretical tooth. A one-third improvement (33%!!!!) in your dental status when castrating yourself and using life-long estrogen translates that you will theoretically lose only 2 teeth instead of 3 teeth. And theoretically you will only lose one breast in the process and not two. Luckily both losses can now be replaced with, good as new, implants. Joan L. |
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Yesterday Joan L. commented on the low dose estrogens study just published in the Dec 8 (97) Archives of Internal Medicine. She said, about the findings in the study, Conclusions: Esterified estrogens at doses from 0.3 to 1.25 mg/d, administered unopposed by progestin, PRODUCE A CONTINUUM OF POSITIVE CHANGES on bone and lipids. Plasma estradiol concentrations increased with esterified estrogens dose and were related to positive bone mineral densities. The 0.3-mg dose resulted in positive bone and lipid changes without inducing endometrial hyperplasia. TRUE: doses were from 0.3 to 1.25 estrogen, PLUS 1000 mg calcium a day TRUE: a continuum of positive changes on bone an lipids was observed. The positive changes were only 1% increase in bone density for the low dose estrogen at the price of yearly endometrial biopsies and unknown impact on the breast and a commitment to take this drug for the rest of your life. It is presently unknown if affecting blood lipids even matters for future cardio health. Reports are showing it does not, or is of only minor impact. See a cardiologist for heart health, not a gynecologist. The subjects were intentionally selected to be age 51 which is during the period of normal, self-limiting accelerated bone density loss. This age group in the placebo group will show bone loss because this is expected. Use of estrogen drugs has always shown 2-3% bone density increases, especially when used only for a short period of time. In this case, the low-dose estrogen showed only an approx 1% increase in bone density. This is NOT a cure for the disease osteoporosis. The accelerated bone loss found for 3-6 years post meno which slows down on its own in 3-6 years is NOT the disease osteoporosis. Impacting a surrogate endpoint is NOT studying the disease itself. TRUE: Blood levels of the estrogen were increased with use of the drug and these correlated to impact on the bone. The higher the dose of the drug, the higher the changes in bone density. But the low level dose which did not cause the uterine dysplasias in the two year test period, also had the least effect on the bone, approx only a 1% increase in bone density compared to the typical 2-3% increase for estrogen drug use. The study also showed over time that the blood level dropped for all groups of circulating estrogen which requires that higher doses will be needed in the future to maintain the alleged bone benefit. And this means moving into the clearly unhealthy unopposed use of estrogens at the .6 and 1.5 levels. The trend for -all- blood levels of the drug decreased over the two year period. The .6 and the 1.25 doses had the most impact on the bone but also had the most dramatic unhealthy effects on the endometrium and these groups had the highest drop out rates. And one of these women died from a blood clot, allegedly related to her existing lung cancer (which is odd that they included her in the study of "healthy" women) TRUE: The use of a .3 dose of estrogen (with 1000 mg calcium) resulted in positive changes to the bone and lipids while not showing harm to the endometrium. The use of the word "positive" must not be interpreted as "beneficial." The study showed that there was perhaps a 1% bone density increase during a normal time of bone density decrease. No one knows if it is beneficial or not to turn off the bodies normal regulatory process at this unique period of immediate post-meno bone remodeling. Higher bone density has been linked in two studies to higher breast cancer rates. Intentionally choosing to study an age group where the placebo group is guaranteed to show bone loss during the normal post-meno bone remodeling, is what is called lying with statistics or intentionally skewing the test results to get a pre-set conclusion. Changing the bone density at meno, age 51, requires you take this drug for life, (approx 35 more years) at higher and higher doses to maintain this artificial level of bone density. Otherwise, if you stop, your bone density levels will return to what they were before you started the drug. And you may find you will lose your uterus from the long tern use of unopposed estrogens at higher and higher doses. It took many more than 2 years to find the uterine -cancer- cases when unopposed estrogen were recommended in the 1960's when the doses were a lot higher. The uterine dysplasias showed up right away for the higher doses, but the cancer stats came much later. NB: Read the full study,
read the conclusions and read the media articles and draw your own conclusions.
And ponder that the driving motive for conducting this ERT study in the
first place was their finding that the added use of progestins (HRT) is
counter productive for bone density.
1. Too short
Joan L.
Will somebody please clarify for me what is meant by "X improved bone density by Y%"? Is this
If my 73% bone is improved 2% does that make it 75%, or do we assume it *would* have been say 72% after a year, and the 2%improvement means it is now 74%? On the other hand maybe this improvement is after 10 years use so I've taken it for 10 years to go from 71% to 73% instead of losing further bone to maybe 50% - or will I be at 52% instead of 50%....... My confused questioning is purely an attempt to understand precisely what I am dealing with statistically and is totally divorced from the question of whether the measurement of a surrogate endpoint is of any practical consquence in osteoporosis. Pat (Crone) Pat,
Unless explicitly said, there is no accounting for the control group in such reporting. One may take a percent change in the experimental group, after three years for example, subtract it from the control group's change and call it "percent change over control over three years." The use of percent change can obviously be confounded by the absolute starting place. For example, at age 30, assuming perfectly fine bone mass, the percent change of XX absolute change in bone mineral density will be far less than for someone with profound bone loss, starting with a smaller number. Does this make sense? I've been crusading for use of absolute numbers (change in g/cm^2) in reporting, but using populations with very low bone mass can give such high percent change, it's tempting to emphasize that means of expression. It's not wrong, you just have to look to the caveats. So, the critical questions to ask when evaluating such data are: from what starting point, over what period, and compared with whom? Hope this helps. Doug Axelrod M.D., Ph.D. Here's the disclaimer: Recent past Medical Director for Bone and Mineral Research, Procter & Gamble Pharmaceuticals, now Manager, Bone Research Discovery, Procter & Gamble Pharmaceuticals. These opinions are my own. |